Your Aims > Health & Fitness QuestionnaireIan Evans2021-02-24T09:28:03+00:00 Your aims and goals: Health & Fitness Questionnaire The studio, name, email, etc will not be in the live / finished version. Step 1 of 6 16% This field is hidden when viewing the formEMS Studio*HarrogateThis field is hidden when viewing the formName* First Last This field is hidden when viewing the formEmail Address:* This field is hidden when viewing the formMobile Number:*Health: Fitness, Stress & Sleep1. Over the last 12 months how would you say your health has been?* Very good Good Okay Poor Very poor 2. Do you have any long-term illness, health problem or disability that limits your daily activities or the work that you can do?* Yes No 3. How would you rate your level of physical fitness compared to others of your age?* Very good Good Okay Poor Very poor 4. How would you rate your level of mental stress compared to others of your age?* Very good Good Okay Poor Very poor 5. How long do you sleep at night?* Less than 4 hours 4 to 6 hours 7 to 8 hours 8 hours and more Health: Diet & Nutrition6. How healthy do you consider your diet?* Very good Good Okay Poor Very poor 6.1. Are you aware pairing EMS training with good nutrition accelerates results?* Yes No 6.2. How likely are you to book in with our FREE nutritionist to help you achieve your goal(s) faster?* Very Likely Likely Unlikely Not Interested 7. What foods and drinks do you consume regularly? Tick as many as apply to you. Fizzy or high sugar drinks Coffee or tea Chocolate, cake, or sweets Fruit Vegetables Rice or pasta Fried food Red meat Chicken Pulses Wholegrain food Low-fat products Ready meals Nuts or seeds Fish or seafood Takeaways 8. Are you happy with your current weight?* Yes No 8.1. If No, how much excess weight would you like to lose?* 1 to 5kg 5 to 10kg 11 to 15kg 16 to 20kg 20kg+ 8.2. Are you planning on, or currently using any type of GLP1 fat loss drug?* Yes No 9. Do you drink alcohol?* Yes No 9.1. If Yes, how often?* Once a week Twice a week Three times a week Four times a week Five or more times a week 10. Do you smoke / vape?* Yes No 10.1. If yes, how many times a day?* Less than 5 4 to 7 8 to 13 13 to 20 20+ times a day I Vape Lifestyle: Fitness Routine11. Over the past 12 months have you done any of the following to try to keep fit and healthy? Tick as many as apply to you.* Follow a fitness programme at a gym or leisure centre Play sport regularly Walk Jog Run Cycle Diet Tried to reduce or give up smoking Tried to reduce or give up drinking alcohol Other (please specify) 11.1. "Other" Past 12 months to keep fit and healthyPlease list, using a comma "," to separate items to max of 10.12. Do you get at least twenty minutes of exercise or activity each day?* yes Most days (4 out of 7) Some days (2 out of 7) No 13. Would you like to do more exercise and physical activity?* Yes No 14. Do you limit the amount of sugar and salt in your diet?* Yes No 15. Do you eat at least five fruits and vegetables each day?* Yes No Lifestyle: Health16. Do you see a GP/Doctor if you feel something is wrong?* Yes No 17. Over the past 12 months have any of the following areas put you under high levels of stress? Tick as many as apply to you.* Work responsibilities Financial worries Family problems Your own health Other (please specify) 17.1. "Other" Past 12 months relating to high levels of stressPlease list, using a comma "," to separate items to max of 10.18. Have you tried to reduce or manage stress in your life over the last 12 months by doing any of the following? Tick as many as apply to you.* Take a holiday Reduce your working hours Take regular exercise Take up a new hobby or leisure activity Take medication Other (please specify) 18.1. "Other" Past 12 months to manage stress in your lifePlease list, using a comma "," to separate items to max of 10.19. Do you want to lose weight and manage your body shape?*Lose weight, Tone & firmBody shape, Tone & firmLose weight20. Do you have family and friends ready to help and support you if needed?* Yes No Fitness: Aims & Goals21. Are you happy with your current fitness level?* Just starting out on your fitness journey Want to improve your fitness levels Want to advance your current fitness level Want to transform your fitness 22. Rate your current fitness level on a scale of 1 (Low) to 10 (High)*1 being low and 10 high level of fitness 1 2 3 4 5 6 7 8 9 10 23. How often do you work out a week?* 0 days 1-2 days 3-4 days 5+ days 24. Where do you work out?* Gym Personal Trainer Group Exercise Classes Group fitness (Public e.g. running club) Home Gym Other (please specify) 24.1. "Other" Where do you work out?Please list, using a comma "," to separate items to max of 10.25. What form of exercise do you currently do?* Cardio Strength training Cardio and strength training None Other (please specify) 25.1. "Other" What form of exercise?Please list, using a comma "," to separate items to max of 10. 26. What is your main motivation for working out?* Specific occasion e.g. wedding or holiday Help relieve pain Body toning and shaping Mental health benefits The buzz (endorphin release) "Feel Electric" Part of a healthy lifestyle 27. In your opinion, how much time per session do you need to work out to see real body change?* 10-20 minutes 30-45 minutes 45-60 minutes 60+ minutes 28. What stops you from working out more often?* Time Money Motivation Work Lifestyle Family commitments 29. What do you know about EMS training?* A lot A little Nothing 30. What health and fitness benefits do you think EMS training can help you achieve? Toning and shaping Get fitter Help relieve pain Lose Weight Body / Bio Hacking Other (please specify) 30.1. "Other" benefits do you think EMS training can help you achieve?Please list, using a comma "," to separate items to max of 10.
